Anterior Cruciate Ligament Injury: Patient Information
What is anterior cruciate ligament (ACL)?
The ACL is an important stabilizing ligament in the knee. It connects the thighbone (femur) to the shinbone (tibia). It keeps the femur from rotating too far, and from moving too far forward over the tibia.
Why the treatment for ACL injury is necessary?
The treatment is necessary for the patient to overcome the episodes of giving way and regain confidence in his knee which should allow a return to work and sport. By stabilising the knee we can protect it from further damage to other structures in knee – such as meniscus, cartilage and possibly osteoarthritis in future.
How is the ACL injury treated?
ACL injuries are treated with surgery and post-surgical rehabilitation or a non-surgical rehabilitation program. The decision to have surgery is based upon several factors, including the person’s age, level of activity, and the presence of other knee injuries.
Surgical treatment
ACL once torn does not heal and requires reconstruction. Surgery is indicated in young active patients to allow them to lead an active lifestyle.
Surgery to reconstruct the ACL is done with less invasive arthroscopy using small incisions. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times. Most patients go home the next day of the surgery.
A graft is required to reconstruct the ACL and is usually harvested from patient’s own body during the surgery. (Patellar tendon graft or hamstring tendon graft).
Post-surgical Rehabilitation
No bed rest. You are able to walk with support the same day. A supervised physiotherapy program is initiated afterwards. You are able to attend your office after 1 week and driving is allowed after 2 weeks.
Majority patients who have surgical reconstruction of the ACL have an excellent outcome. Athletes can return to sports generally after 9 to 12 months, depending upon the sport and the person’s dedication to the rehabilitation program.
Posterior Cruciate Ligament (PCL)
What is posterior cruciate ligament (PCL)?
The PCL is an important stabilizing ligament in the knee. It connects the thighbone (femur) to the shinbone (tibia).It prevents backwards movement of the tibia on femur, prevents hyperextension of the knee, bending backwards on itself, and stabilises the knee on rotational movements acting as a central axis of rotation.
How is the PCL injury diagnosed?
PCL injury can be diagnosed after taking a detailed medical history and physical examination. X-rays and MRIs are helpful in confirming the diagnosis and detecting any other structures of the knee that may be injured.
How is the PCL injury treated?
Less severe isolated PCL tears (Grade 1 and 2) are usually treated with a progressive rehabilitation program. Treatment in this group consists of protected weight bearing, early range of motion and aggressive physical therapy emphasising quadriceps muscle strengthening and proprioceptive training,
Surgical Treatment
It is indicated symptomatic grade 3 PCL injury, PCL injury associated with bony avulsion and combined ligament injuries.
Surgery to reconstruct the PCL is done with less invasive arthroscopy using small incisions. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times. Most patients go home the next day of the surgery.
A graft is required to reconstruct the PCL and is usually harvested from patient’s own body during the surgery. (Patellar tendon graft or hamstring tendon graft).
Post-surgical Rehabilitation
No bed rest. Toe touch weight bearing walking with crutches is recommended for 2-3 weeks for the PCL graft. Full weight bearing walking with support is allowed after 3 weeks and patient can attend his work after 3 weeks. The knee is held within a brace with a range of movement from full extension (straightening) to 90° flexion (bending) for 8-10 weeks.
Exercises are gradually stepped up in intensity and return to sports following PCL reconstruction is anticipated 9-12 months following surgery, and requires sport-specific functional training.
Meniscal Injury: Patient Information Sheet
What is Meniscus? The meniscus is a C- shaped tough fibrous cartilage that acts as a shock absorber in the knee joint between the thigh bone (femur) and shin bone (tibia). There are two menisci in the knee, one on the inside of the knee -the medial meniscus. The other rests on the outside of the knee – the lateral meniscus.
How is the meniscal injury diagnosed?
Meniscal injury can be diagnosed on the history and physical examination of the knee. MRI scan is required to confirm the diagnosis and see other associated injuries if any.
Why is the treatment for meniscal injury necessary?
The treatment is necessary for the patient to overcome the episodes of recurrent pain and swelling in the knee joint. Also, the constant rubbing of the torn meniscus on the cartilage may cause wear and tear on the surface, leading to degeneration of the joint.
How is the meniscal injury treated?
Conservative treatment
If the tear is minor or the symptoms that are mild do not interfere with the daily activities, conservative treatment like muscle strengthening and rehabilitation exercises are required.
Surgical Treatment
Surgical treatment is warranted in cases of:
failed conservative management,
freshly injured patients in whom the knee cannot be straightened (locked knee),
Chronic symptomatic patients in whom symptoms interfere with occupation and/or sports.
Surgical treatment depends on the age of the patient, type of tear, the size and location of the tear. This is done by less invasive arthroscopic (keyhole) surgery. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times. Most patients go home the next day of the surgery.
Meniscal Repair
This is done in young patients with traumatic tears which are present in the outer boundary of the meniscus. In the outer region of meniscus, the blood supply is good and healing usually occurs.
Partial Removal of torn meniscus (Partial Menisectomy)
This is done in cases where a repair is not possible. The torn section of meniscus is removed and the rest is trimmed and smoothened. As much as possible normal meniscus is preserved in order to maintain the cushioning effect.
Post-op Rehabilitation
Following surgery, physiotherapy is advised to keep the knee joint active (which encourages healing) and to strengthen up the surrounding muscles to give support and strength to the knee. Patients are able to walk the next day with support of crutches and can return to work in about 4 weeks’ time.
Cartilage
Cartilage is the “Life” of knee and other joints. Once the cartilage is damaged the joint becomes painful and stiff. Certain procedures can help in cartilage restoration.
What is articular cartilage?
Articular or hyaline cartilage is the smooth layer of tissue covering the ends of 2 bones where they touch and form a joint such as the knee or hip. The cartilage layer provides a smooth, slippery surface allowing the joint to move through frictionless range of motion during daily activities such as walking or high impact sporting activities.
How is articular cartilage defect (injury) diagnosed?
Articular cartilage injury is difficult to diagnose on clinical examination. MRI evaluation is necessary to identify the presence, location and size of the defect. MRI is also important to rule of injury to other structures (ligaments, meniscus). Arthroscopic examination is the most useful to assess the full extent of injury.
Why is articular cartilage repair necessary?
Articular cartilage does not have its blood supply and has very limited capacity to heal on its own. Left untreated this condition progresses and becomes more extensive. Patient experiences increasing pain and inability to perform regular activities of daily living without significant pain and discomfort.
What are options for treatment?
The decision to treat a cartilage lesion depends on age of the patient and desired level of activity. It is also dependent on location, size and number of defect(s) and associated injuries.
Cartilage restoration techniques require extensive periods of recovery and therapy. To ensure best outcome, patient must be committed to the rehabilitation protocol.
Typical options for treatment include:
Microfracture is an arthroscopic procedure that works best for treatment of small cartilage injuries. Microfracture involves drilling small holes into the bone at the defect site to stimulate new blood and bone marrow to enter the site and promote new cartilage formation.
Osteochondral Autograft Transplantation (OATS or MosaicPlasty) typically best for slightly larger focal lesions or those that involve cartilage and bone loss. The surgeon obtains a cartilage tissue from another location in patient’s body (autograft OATS) that is custom sized to fit into the defect to recreate a smooth joint surface.
Autologous chondrocyte implantation is an advanced tissue-engineered articular cartilage repair procedure which is done in 2 stages.
What will happen after surgery?
A post-operative rehabilitation protocol that is dependent on the exact surgical procedure performed and location of the cartilage lesion treated addressing specific range of motion and weight-bearing progressions will be started. Full recovery ranges from 2-6 months dependent on the extent of the surgery.
